Surgery

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advancement flap

tissue stretch from sides of wound

anesthetics, classification

amides: dibucaine hydrochloride (nupercaine), lidocaine

aminobenzoate esters: benzocaine, benoxinate hydrochloride, tetracaine

benzoic acid esters: cocaine, hxylcaine, piperocaine, proparacaine

miscellaneous: cyclomethycaine, dimethisoquin, diperodon, dyclonine, prmoxine

basic surgical tray

#3 blade handle, Adson 1 x 2 delicate tip forceps, Iris scissors 4 ½ curved serrated, 2 single prong skin hooks, 2 Halstead mosquito forceps 5” curved delicate tips, Webster needle holder 5” smooth jawed with tungsten-carbide inserts, Northbent suture scissors 4 ¾

bleeding
Typical causes; coagulopathy (intrinsic or iatrogenic), inadequate intraoperative hemostasis, loose pressure dressing, exertion and/or manipulation of the wound site by the patient

Burrow’s triangle

triangle of tissue removed to facilitate rotation flap

clamp

Chalazion: useful for stabilizing mobile mucosal surfaces

composite graft

graft of skin and other appendage (hair, cartilage) ex: hair transplant autograft

donor sites: antihelix, inferior crus of ear helix, scalp, tragus

curette

1-10 mm, round or oval

dermatomes, electric

Brown (Zimmer): most common

Padgett: cumbersome graft width adjustment, because uses shims

Simon-Davol: light, but only one setting (0.015 thick and 1 5/16” wide)

dermatomes, free hand

Blue blade, Weck knife

digital nerve block

lidocaine without epinephrine, use < 2 cc, may use EMLA

dog ear

AKA redundant edge tissue, standing cutaneous cone, triangular redundant tissue

donor site--graft site

superior retroauricular area/upper eyelid--lower eyelid,    lower retroauricular area--cheek/temple, preauricular area/lower lateral neck--mid cheek/chin,     supraclavicular area-medial canthus/lower eyelid,   upper lateral neck--helix,    glabella--chin/forehead/nose   inguinal fold/antecubital fold--hand,   nasolabial fold--nose

EMLA

eutetic mixture of local anesthetics

epinephrine

1:100,000-1:300,000 epi:lidocaine.  Controversial (and routinely disregarded): avoid on ears, fingers, nose, penis, toes

forceps (pickups)

Adson: most common forcep, smooth, serrated, toothed (1 x 2), may have suturing platform

Allis: tightly grasping tissue for mobilization (cyst removal)

Bishop-Harmon: use for delicate tissue, 3 holes in handle, smooth, serrated, toothed (1 x 2)

Brown Adson: 7-8 grasping teeth per side to grasp heavy tissue

DeJardin: wide jaws, 8 teeth per side (horizontal) for cartilage

Iris: narrow handle, delicate tissue, smooth, serrated or toothed (1 x 2)

forehead flap

may involve supratrochlear artery

freer elevator

instrument for use in nail removal

full thickness skin graft

ex: dog ear graft

fusiform shape

3:1 ratio (except on back 1-1.5:1)

glabellar rotation flap

nose

gold handles

tungsten-carbide inserts in instruments

hematoma
acute/expanding; occurs within hours of surgery; edema, throbbing pain
stable; present days after surgery; evolve from amorphous to organized (firm) to liquified (dissolved). 

hemostats (snaps)

Halstead, Mosquito, Jacobsen

Hibiclens

avoid use around eyes, ear canal (use povodone/iodine)

infection
Typical rate in dermatologic surgery is 2-3%.  Observed 3-7 days after surgery with increasing erythema, edema, pain, and warmth.  Increased risk with contamination, trauma to the tissue, excess tension, presence of dead space.  Inadequate post operative wound care, patient colonization with potentially virulent bacteria (Staph aureus, MRSA). 

island pedicle flap

near nasal ala

kite flap

see island pedicle flap

margins

BCC: 4 mm  dysplastic nevus: 2 mm  melanoma: 1 cm  nevus: no margin

methylene blue

dye used to mark tumor margin, orientation

Mohs micrographic surgery

stepwise tumor removal with microscopic control allowing maximum preservation of normal tissue

Mohs micrographic surgery, indications

BCC: morpheaform, perineural, recurrent

embryonic fusion planes: nasolabial fold, columella, preauricular, postauricular

size: > 1 cm head & neck, > 2 cm trunk & extremities

tissue conservation: ear, eyelid, genitalia, lips

tumor type: malignant fibrous histiocytoma, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans, merkel cell carcinoma

miscellaneous: scar carcinoma, immunocompromised

m-plasty

30° angle to save tissue

mucosal advancement flap

no subcutaneous stitches, use silk

myocutaneous flap

nose

needle holders

Castroviejo: spring action, rotary clasp, very fine jaws for fine needles, occuloplastic surgery

Crilewood: similar to Webster

neuro-smooth: similar to Webster

Derf: similar to Webster

Halsey: similar to Webster

Olsen-Hegar: scissors behind jaws for cutting suture

Webster: most popular, variable length & fineness

O to H

eyebrow, rim of ear, (+/-)lip

O to Z

forehead, chin, large defects

recurrence, BCC

cryotherapy 7.5%, ED & C 8%, Mohs’ 1%, radiation 9%

recurrence, recurrent BCC

ED & C 40%, excision 17.4%, Mohs’ 5.6%, radiation 9.8%

recurrence, SCC

Mohs’ <2cm: 1.9%, >2cm: 25.2%

rhomboid flap

120° and 60° angles, rotate around 60° angle

rotation flap

move adjacent tissue in arc

scalpel blade

#10 large blade, sharp belly, use for large lesions and thick tissue

#11 sharp, pointed blade, use for incision & drainage, sharp angles, close margins

#15 most versatile tip

#15C similar to #15 with narrower, more sharply tapered tip, use for small lesions or delicate tissue

scissors

bandage: heavy scissors with bulbous lower blade end to cut bandage

Gradle: slightly curved short blade, delicate work

iris: most commonly used scissors, used for dissection & undermining

Metzenbaum: long handle & blade, useful for tissue undermining

LaGrange: deeply curved sharp tips, handles with reverse curve, dissecting deep concave surfaces &     

             removing hair transplant grafts

Stevens tenotomy: similar to Gradle with longer blade

suture: heavy blades, notch at end aid in suture removal

Westcott: spring action, fine tips, eye lid work

skin hooks (rakes)

Frazier, Guthrie, Lahey

split thickness skin graft (STSG)

full thickness epidermis & partial thickness dermis ex: pinch graft

donor sites: abdomen, anterior thigh, back, buttocks, scalp

subcutaneous suture

avoid on: ear, eyelid, (+/-)forehead

suture

absorptive: Vicryl

slow absorptive: Maxon, PDS

non-absorptive: Proline

tattoo pigments

blue; cobalt aluminate

blue/black; carbon

brown; ochre iron oxides

green; chromic oxide/chromium sesquioxide

light blue; cobaltous aluminate

red; cinnabar & vegetable dyes, mercury, mercury sulfide (red cinnabar)

yellow; cadmium sulfide

terrible tetrad
bleeding, dehiscence, infection, necrosis

tip stitch

½ buried mattress suture

transposition flap

moves across tissue; bilobe, forehead, nasolabial, rhomboid

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